BRITISH MEDICAL JOURNAL
1043
22 OCTOBER 1977
and almost certainly impossible while carrying a major clinical commitment. In such circumstances entrenched resistance may gain its apparent justification. Enthusiasts might consider that more respect will be gained in the long run by stating exactly what given resources can buy and ensuring that the quality of what is then offered is measurable in its depth rather than-as at present may be the case-in its unrealistic breadth. If at length some principles do emerge on which to base the future development of academic general practice, the first must be that academic investment should not be made conditional on service-earning capacity. The second is probably that the "continuing genuine service role" for academic general practitioners provides a spurious and incomplete respectability if it is maintained at the expense of providing teaching and research of the standard the University Grants Committee would rightly like to see more generally evident before committing itself in print to a more progressive
warfarin, colaspase (L-asparaginase), and azathioprine were thought to be responsible in a few patients each, and recently pancreatitis has been reported after paracetamol poisoning.'4 It may complicate any type of operation and may be a sequel to renal transplantation.6 Two diagnostic proceduresendoscopic retrograde cholangiopancreatography' and translumbar aortography8-may also be followed by pancreatitis. The clinician faced with a patient with acute pancreatitis should always inquire about drugs, but it is unlikely that any single observer wvill see enough cases to be sure of an association. If a drug is suspected it should be reported to the Committee on Safety of Medicines, whose recently updated list of adverse reactions contains a section on pancreatitis"; and perhaps the Pancreatic Society of Great Britain and Ireland"' might bring new causes to light by undertaking a survey of iatrogenic pancreatitis encountered by their members. IMyren, J, Scanzdinavian Journal of Gastroenterolog_y, 1977, 12, 513. 2 Nakashima, Y, and Howard, J M, Surgery, Gytnecology and Obstetrics,
position. I
1977, 145, 105.
Graeber, G M, et al, Archives of Surgery, 1976, 111, 1014. 4Gilmore, I T, and Tourvas, E, British Medical ouirrnal, 1977, 1, 753. Coward, R A, British Medicalyo/ornal, 1977, 1, 1086. Fernandez, J A, and Rosenberg, J C, Surgery, Gynecology anid Obstetrics,
3iutislh Medical 7ournal, 1975, 4, 724.
latrogenic pancreatitis In spite of considerable research a good deal of mystery still surrounds the pancreas. There is no simple and foolproof way of studying its appearance and behaviour in disease; our knowledge of the various forms of pancreatitis is limited, and treatment of them is far from satisfactory. Acute pancreatitis, for example, affects about 2500 people a year in Britain (twice as many in the United States), of whom some 500 die.1 An association has been established with gall stones, alcoholism, hyperlipidaemia (especially types IV and V), and virus infections and this accounts for some three-quarters of the cases; but just how these various agents damage the pancreas is not always clear. Such factors as anatomical variations in the biliary and pancreatic ducts, a direct toxic effect of alcohol, increase of tissue-digesting enzymes, abnormal composition of the bile, and immunological reactions on the part of the pancreas have been postulated, but it may remain difficult to pinpoint a cause in an individual patient. This is particularly true in the case of drugs, where an association may not be considered because of the nature of the underlying disease. Quite a number of drugs have been reported to cause pancreatitis, and a recent review2 of 112 cases from English language papers up to 1975 is a useful guide for the clinician. Corticosteroids headed the list with 51 examples. Equal numbers of adults and children were affected, though males predominated. There did not seem to be any connection with the underlying disease, but patients with the nephrotic syndrome, asthma, and disseminated lupus erythematosus were common. The dose, duration, and type of corticosteroid were immaterial. Prognosis for an attack of pancreatitis was poor, probably because symptoms were masked by the drug. The contraceptive pill also caused pancreatitis (and gall stones) on rare occasions, and sometimes this was due to a pre-existing hyperlipidaemia. The next largest group was antibiotics, of which rifampicin was responsible in 20 patients, and almost as many cases were reported with different diuretics, where an allergic vasculitis might have been the cause. Phenformin,3 clonidine, salicylates, dextropropoxyphene, calcium (the association with hyperparathyroidism is well recognised),
1
1976, 143, 795. Bilbao, M K, et al, Gastr)oenterology, 1976, 70, 314. Imrie, C W, et al, British Medical Journal, 1977, 2, 681. Committee on Safety of Mcdicines, Register- of Adverse Reactions, 1977, 6, 451. Secretary: Michael Knight, FRCS, St George's Hospital, Hyde Park Corner, London SWIX 7EZ.
Oust the louse Head louse infestation is thought to be getting more common in children, with an incidence of 1O`0 to 12 50 in some parts of Britain.' -: Infestation is by no means unusual in adults.4 Lice often go unnoticed since no symptoms arise unless the host is sensitised to their salivary antigens, when there may be pruritus of the scalp and an urticarial eruption over the neck and shoulders. Secondary pyogenic infection in the excoriated scalp causes enlargement of the cervical lymph nodes, and louse infestation must be considered a possibility in cases of impetigo. Silent infestations may be discovered only by close inspection of the scalp, when the ova (nits) may be seen fixed to the hairs, though the adult lice may not be visible. A national campaign to eradicate the head louse started in September this year and will continue for several weeks. The area health authorities of England and Wales are mounting the project, which has been co-ordinated by the Health Education Council. The main priority is the inspection of millions of schoolchildren, though all age groups, including child play groups and the elderly, will be examined. The public will also be educated in how to recognise louse infestation and how to get treatment. So they may well ask their family doctors how it is picked up and how it can be treated. Head lice spread by close human contact, and infestation is most common in children below school age.5 In boys the incidence used to fall during the school years, but in 1969 Wilson' found a smaller difference between the rates of infestation of girls and boys at school. Possibly the fashion for long hair in both sexes played some part in this. For some years pediculosis has been treated with DDT or gamma benzene hydrochloride, but in 1971 Maunder6 reported that in at least 20 areas in Britain lice had become resistant to organochlorine insecticides. Furthermore, they do
1043
22 OCTOBER 1977
and almost certainly impossible while carrying a major clinical commitment. In such circumstances entrenched resistance may gain its apparent justification. Enthusiasts might consider that more respect will be gained in the long run by stating exactly what given resources can buy and ensuring that the quality of what is then offered is measurable in its depth rather than-as at present may be the case-in its unrealistic breadth. If at length some principles do emerge on which to base the future development of academic general practice, the first must be that academic investment should not be made conditional on service-earning capacity. The second is probably that the "continuing genuine service role" for academic general practitioners provides a spurious and incomplete respectability if it is maintained at the expense of providing teaching and research of the standard the University Grants Committee would rightly like to see more generally evident before committing itself in print to a more progressive
warfarin, colaspase (L-asparaginase), and azathioprine were thought to be responsible in a few patients each, and recently pancreatitis has been reported after paracetamol poisoning.'4 It may complicate any type of operation and may be a sequel to renal transplantation.6 Two diagnostic proceduresendoscopic retrograde cholangiopancreatography' and translumbar aortography8-may also be followed by pancreatitis. The clinician faced with a patient with acute pancreatitis should always inquire about drugs, but it is unlikely that any single observer wvill see enough cases to be sure of an association. If a drug is suspected it should be reported to the Committee on Safety of Medicines, whose recently updated list of adverse reactions contains a section on pancreatitis"; and perhaps the Pancreatic Society of Great Britain and Ireland"' might bring new causes to light by undertaking a survey of iatrogenic pancreatitis encountered by their members. IMyren, J, Scanzdinavian Journal of Gastroenterolog_y, 1977, 12, 513. 2 Nakashima, Y, and Howard, J M, Surgery, Gytnecology and Obstetrics,
position. I
1977, 145, 105.
Graeber, G M, et al, Archives of Surgery, 1976, 111, 1014. 4Gilmore, I T, and Tourvas, E, British Medical ouirrnal, 1977, 1, 753. Coward, R A, British Medicalyo/ornal, 1977, 1, 1086. Fernandez, J A, and Rosenberg, J C, Surgery, Gynecology anid Obstetrics,
3iutislh Medical 7ournal, 1975, 4, 724.
latrogenic pancreatitis In spite of considerable research a good deal of mystery still surrounds the pancreas. There is no simple and foolproof way of studying its appearance and behaviour in disease; our knowledge of the various forms of pancreatitis is limited, and treatment of them is far from satisfactory. Acute pancreatitis, for example, affects about 2500 people a year in Britain (twice as many in the United States), of whom some 500 die.1 An association has been established with gall stones, alcoholism, hyperlipidaemia (especially types IV and V), and virus infections and this accounts for some three-quarters of the cases; but just how these various agents damage the pancreas is not always clear. Such factors as anatomical variations in the biliary and pancreatic ducts, a direct toxic effect of alcohol, increase of tissue-digesting enzymes, abnormal composition of the bile, and immunological reactions on the part of the pancreas have been postulated, but it may remain difficult to pinpoint a cause in an individual patient. This is particularly true in the case of drugs, where an association may not be considered because of the nature of the underlying disease. Quite a number of drugs have been reported to cause pancreatitis, and a recent review2 of 112 cases from English language papers up to 1975 is a useful guide for the clinician. Corticosteroids headed the list with 51 examples. Equal numbers of adults and children were affected, though males predominated. There did not seem to be any connection with the underlying disease, but patients with the nephrotic syndrome, asthma, and disseminated lupus erythematosus were common. The dose, duration, and type of corticosteroid were immaterial. Prognosis for an attack of pancreatitis was poor, probably because symptoms were masked by the drug. The contraceptive pill also caused pancreatitis (and gall stones) on rare occasions, and sometimes this was due to a pre-existing hyperlipidaemia. The next largest group was antibiotics, of which rifampicin was responsible in 20 patients, and almost as many cases were reported with different diuretics, where an allergic vasculitis might have been the cause. Phenformin,3 clonidine, salicylates, dextropropoxyphene, calcium (the association with hyperparathyroidism is well recognised),
1
1976, 143, 795. Bilbao, M K, et al, Gastr)oenterology, 1976, 70, 314. Imrie, C W, et al, British Medical Journal, 1977, 2, 681. Committee on Safety of Mcdicines, Register- of Adverse Reactions, 1977, 6, 451. Secretary: Michael Knight, FRCS, St George's Hospital, Hyde Park Corner, London SWIX 7EZ.
Oust the louse Head louse infestation is thought to be getting more common in children, with an incidence of 1O`0 to 12 50 in some parts of Britain.' -: Infestation is by no means unusual in adults.4 Lice often go unnoticed since no symptoms arise unless the host is sensitised to their salivary antigens, when there may be pruritus of the scalp and an urticarial eruption over the neck and shoulders. Secondary pyogenic infection in the excoriated scalp causes enlargement of the cervical lymph nodes, and louse infestation must be considered a possibility in cases of impetigo. Silent infestations may be discovered only by close inspection of the scalp, when the ova (nits) may be seen fixed to the hairs, though the adult lice may not be visible. A national campaign to eradicate the head louse started in September this year and will continue for several weeks. The area health authorities of England and Wales are mounting the project, which has been co-ordinated by the Health Education Council. The main priority is the inspection of millions of schoolchildren, though all age groups, including child play groups and the elderly, will be examined. The public will also be educated in how to recognise louse infestation and how to get treatment. So they may well ask their family doctors how it is picked up and how it can be treated. Head lice spread by close human contact, and infestation is most common in children below school age.5 In boys the incidence used to fall during the school years, but in 1969 Wilson' found a smaller difference between the rates of infestation of girls and boys at school. Possibly the fashion for long hair in both sexes played some part in this. For some years pediculosis has been treated with DDT or gamma benzene hydrochloride, but in 1971 Maunder6 reported that in at least 20 areas in Britain lice had become resistant to organochlorine insecticides. Furthermore, they do
